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Muhammad FS, Shahabudin SM, Talib MBA. Measuring spatial inequalities in maternal and child mortalities in Pakistan: evidence from geographically weighted regression. BMC Public Health 2024; 24:2229. [PMID: 39152373 PMCID: PMC11328511 DOI: 10.1186/s12889-024-19682-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 08/02/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND In developing countries, the death probability of a child and mother is more significant than in developed countries; these inequalities in health outcomes are unfair. The present study encompasses a spatial analysis of maternal and child mortalities in Pakistan. The study aims to estimate the District Mortality Index (DMI), measure the inequality ratio and slope, and ascertain the spatial impact of numerous factors on DMI scores across Pakistani districts. METHOD This study used micro-level household datasets from multiple indicator cluster surveys (MICS) to estimate the DMI. To find out how different the DMI scores were, the inequality ratio and slope were used. This study further utilized spatial autocorrelation tests to determine the magnitude and location of the spatial dependence of the clusters with high and low mortality rates. The Geographically Weighted Regression (GWR) model was also applied to examine the spatial impact of socioeconomic, environmental, health, and housing attributes on DMI. RESULTS The inequality ratio for DMI showed that the upper decile districts are 16 times more prone to mortalities than districts in the lower decile, and the districts of Baluchistan depicted extreme spatial heterogeneity in terms of DMI. The findings of the Local Indicator of Spatial Association (LISA) and Moran's test confirmed spatial homogeneity in all mortalities among the districts in Pakistan. The H-H clusters of maternal mortality and DMI were in Baluchistan, and the H-H clusters of child mortality were seen in Punjab. The results of GWR showed that the wealth index quintile has a significant spatial impact on DMI; however, improved sanitation, handwashing practices, and antenatal care adversely influenced DMI scores. CONCLUSION The findings reveal a significant disparity in DMI and spatial relationships among all mortalities in Pakistan's districts. Additionally, socioeconomic, environmental, health, and housing variables have an impact on DMI. Notably, spatial proximity among individuals who are at risk of death occurs in areas with elevated mortality rates. Policymakers may mitigate these mortalities by focusing on vulnerable zones and implementing measures such as raising public awareness, enhancing healthcare services, and improving access to clean drinking water and sanitation facilities.
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Affiliation(s)
- Farzana Sher Muhammad
- Faculty of Business and Economics, Universiti Malaya, Kuala Lumpur, 50603, Malaysia.
- Department of Economics, Faculty of Management Science, Sardar Bahadur Khan Womes University Balochistan, Quetta, 08763, Pakistan.
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S R, Neethi Mohan V, Vaidyanathan G, Dash U, Muraleedharan VR. Wealth and education-related inequalities in the utilisation of reproductive, maternal, newborn, and child health interventions within scheduled tribes in India: an analysis of Odisha and Jharkhand. BMC Public Health 2024; 24:1605. [PMID: 38886705 PMCID: PMC11181544 DOI: 10.1186/s12889-024-18857-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 05/15/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND The utilisation of Reproductive, Maternal, Newborn and Child Health (RMNCH) services remains lower among the Scheduled Tribes (ST) in India than among the rest of the country's population. The tribal population's poorest and least-educated households are further denied access to RMNCH care due to the intersection of their social status, wealth, and education levels. The study analyses the wealth- and education-related inequalities in the utilisation of RMNCH services within the ST population in Odisha and Jharkhand. METHODOLOGY We have constructed two summary measures, namely, the Co-coverage indicator and a modified Composite Coverage Index (CC), to determine wealth- and education-related inequalities in the utilisation of RMNCH indicators within the ST population in Odisha and Jharkhand. The absolute and relative inequalities with respect to wealth and education within the ST population are estimated by employing the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII). RESULTS The results of the study highlight that access to RMNCH services is easier for women who are better educated and belong to wealthier households. The SII and RII values in the co-coverage indicator and modified CCI exhibit an increase in wealth-related inequalities in Odisha between NFHS-4 (2015-16) and NFHS-5 (2019-21) whereas in Jharkhand, the wealth- and education-related absolute and relative inequalities present a reduction between 2016 and 2021. Among the indicators, utilisation of vaccination was high, while the uptake of Antenatal Care Centre Visits and Vitamin A supplementation should be improved. INTERPRETATION The study results underscore the urgent need of targeted policies and interventions to address the inequalities in accessing RMNCH services among ST communities. A multi-dimensional approach that considers the socioeconomic, cultural and geographical factors affecting healthcare should be adopted while formulating health policies to reduce inequalities in access to healthcare.
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Affiliation(s)
- Rekha S
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India.
| | - Varshini Neethi Mohan
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India
| | - Girija Vaidyanathan
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India
| | - Umakant Dash
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India
- Institute of Rural Management Anand, Anand, Gujarat, India
| | - V R Muraleedharan
- Department of Humanities and Social Sciences (DoHSS), Indian Institute of Technology (IIT), Madras, India
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Kundu S, Sharma P, Singh S, Kumar P. District-level heterogeneity in overweight or obesity among women of reproductive age: A geo-spatial analysis in India. PLoS One 2023; 18:e0290020. [PMID: 37590188 PMCID: PMC10434895 DOI: 10.1371/journal.pone.0290020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/01/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Globally by 2030, 38% of the world's population would be overweight, and another 20% would be obese. This has led to rising concerns regarding how swiftly and substantially the world is moving towards this epidemic of "globesity". India too is facing an increased burden of overweight and obese population. The changing dietary patterns are significantly associated with the increasing prevalence of overweight/obesity and related complications, especially among women. Hence, the present study aims to observe the spatial patterns of overweight or obesity among women in reproductive age group in India and factors associated with it. METHODS The study analyzed data from a cross-sectional nationwide household survey, i.e. National Family Health Survey (NFHS-4), 2015-16. The primary outcome variable of this study was overweight/obesity among reproductive-age women, which was measured through the body mass index (BMI) of the women. Bivariate and multivariate logistic regression analysis was used to analyze the data. Additionally, for spatial analysis in terms of overweight/obesity among women in India, univariate and bivariate Moran's I index measurements were used along with the usage of spatial regression models. RESULTS The value of spatial-autocorrelation for overweight or obese was 0.64, which depicts the moderately high prevalence of the overweight/obesity coverage over districts of India. The overall prevalence overweight/obesity among women in India is around 25% and higher proportion of women from urban areas (37.8%), and non-poor (33.4%) economic group reported to be overweight or obese. From spatial lag model, the lag coefficient was found to be 0.28, implying that a change in the prevalence of overweight/obesity among women in a certain district may statistically lag the prevalence of overweight/obesity by 28% in the neighbouring districts. There were significantly high clustering of overweight/obese women and non-poor wealth quintiles in 132 districts, mainly from states of Punjab, Haryana, Gujarat, Maharashtra, Kerala, Tamil Nadu, Karnataka and Andhra Pradesh. Additionally, there was high-high clustering of overweight/obese women and those who ever had caesarean in 82 districts, mostly from Kerala, Tamil Nadu, Andhra Pradesh and Karnataka. CONCLUSION The spatial patterns on the prevalence of overweight and obesity in India show that the women belonging to the southern states' districts are more overweight or obese in comparison to other states. The determinants like older age, higher education, urban residence, higher economic status are the key factors contributing to the prevalence of overweight or obesity among women in the reproductive age group. The study concludes and recommends an urgent need of interventions catering to urban women belonging to higher socio-economic status, to reduce the risks of health consequences due to overweight and obesity.
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Affiliation(s)
- Sampurna Kundu
- Centre of Social Medicine and Community Health, Jawaharlal Nehru University, Delhi, India
| | - Pratima Sharma
- School of Health System Studies, Tata Institute of Social Sciences, Mumbai, India
| | - Shivani Singh
- Specialist- Monitoring and Evaluation, India Health Action Trust (IHAT), Lucknow, India
| | - Pradeep Kumar
- Specialist- Monitoring and Evaluation, India Health Action Trust (IHAT), Lucknow, India
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Tripathy A, Mishra PS. Inequality in time to first antenatal care visits and its predictors among pregnant women in India: an evidence from national family health survey. Sci Rep 2023; 13:4706. [PMID: 36949163 PMCID: PMC10033916 DOI: 10.1038/s41598-023-31902-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 03/20/2023] [Indexed: 03/24/2023] Open
Abstract
For countries with high maternal mortality and morbidity, on-time initiation of antenatal care (ANC) is indispensable. Therefore this paper aims for studying the median survival time (MST) of first ANC among pregnant women as well as understanding the contextual factors that influence a mother's decision to access ANC services in India. The study used cross-sectional survey data obtained from the NFHS-4 conducted in 2015-2016. The MST of the timing of the first ANC visit was estimated using the Kaplan-Meir estimate. A multivariate Cox-proportional hazard regression model was used to identify the factors related to the timing of the first ANC visit with a 95% confidence interval (CI). Overall at least one ANC checkup was assessed by 60.15% of women and the median survival time for the first ANC checkup was found to be 4 months. Early initiation of ANC in pregnant women increased by 37% (AHR: 1.37, CI:1.34-1.39) for primary education, and 88% (AHR:1.88, CI:1.86-1.90) for secondary education compared to women having no formal education. Results of the current study revealed that the median survival time of the first ANC visit was 4 months in India which is delayed compared to recommendations of WHO. Therefore boosting the access and utilization of antenatal care coverage among pregnant women can ensure the best health outcomes for their pregnancy.
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Affiliation(s)
- Abhipsa Tripathy
- Department of Mathematics and Computing, Indian Institute of Technology (ISM), Dhanbad, Jharkhand, 826004, India.
| | - Prem Shankar Mishra
- Department of Population Research Centre, Institute for Social and Economic Change, Bengaluru, Karnataka, 560072, India
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Kumar P, Kundu S, Bawankule R. District Level Geospatial Analysis of Utilization of ICDS Services Among Children in India. Front Public Health 2022; 10:874104. [PMID: 35874987 PMCID: PMC9302607 DOI: 10.3389/fpubh.2022.874104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/30/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Integrated Child Developmental Services (ICDS) is the most extensive government-run health program for children with its foot spread across the complete Indian Territory. ICDS Scheme, has been provided for 40 years and has been successful in some ways. The program in reducing the undernourishment among children over the past decade has been modest and slow in India than what has been reached in other countries with comparable socio-economic measure. Therefore, this study aims to identify the district level clustering of the utilization of ICDS services in India, and the present research also tried to relate it with socio-economic and demographic factors. Materials and Methods The data from the fourth round of the National Family Health Survey (NFHS-4) conducted in 2015-16 in India is used to carry out the analysis. We classified the country in 640 districts and employed geospatial techniques like Moran's I, univariate and bivariate local indicators of spatial association (LISA), and spatial error regression. Results The non-utilization under ICDS scheme varied between 93% in West Siang district of Arunachal Pradesh and around 7% in the Kandhamal district of Odisha in 2015-16 in India. The univariate LISA results suggest striking geographic clustering of utilization of ICDS services among children in India (Moran's I: 0.612). On another hand, there were regions with substantially low-low clustering of non-utilization of ICDS services in southeast India, including districts in Andhra Pradesh, Chhattisgarh, Southern Madhya Pradesh, Odisha, Telangana, and West Bengal. The findings also suggest that the proportion of the rural population (-0.190), and poor households (-0.132) in the district were significantly and negatively related while the proportion of uneducated women (0.450) was positively related to the non-utilization of ICDS services within the district. Conclusion This is the first-ever study that examined the complex interplay of the rural population, female illiteracy, poverty, SC/ST population, and Hindu population with non-utilization of ICDS services among children in the district in India. The study highlights the inter-district geographical disparities in the non-utilization of ICDS services. Further, it confirms that underprivileged districts in terms of the rural population and poor households are also disadvantageous in the utilization of ICDS services.
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Affiliation(s)
- Pradeep Kumar
- Department of Survey Research and Data Analytics, International Institute for Population Sciences, Mumbai, India
| | - Sampurna Kundu
- Department of Survey Research and Data Analytics, International Institute for Population Sciences, Mumbai, India
- Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
| | - Rahul Bawankule
- Department of Biostatistics, MGM Institute of Health Sciences, Mumbai, India
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Godha D, Hotchkiss DR. A decade of conditional cash transfer programs for reproductive health in India: How did equality fare? BMC Public Health 2022; 22:394. [PMID: 35216569 PMCID: PMC8876831 DOI: 10.1186/s12889-022-12563-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 01/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Since 2005, India has implemented conditional cash transfer [CCT] programs to promote the uptake of institutional delivery services [ID]. The study aims to assess changes in wealth-based inequality in the use of ID and other maternal health care services during the first decade of Janani Suraksha Yojana and related CCT programs. Methods Data from two Demographic and Health Surveys were used to calculate changes in service inequality from 2005 to 2015–16 in the use of three or more antenatal care [ANC] visits, ID, and postnatal care [PNC]. The changes were assessed at the national level, within high and low performing states [HPS and LPS, respectively] and within urban and rural areas of each state category. Erreygers Index [EI] and Wagstaff Index [WI], superior to concentration index, were used to gain different insights into the nature of inequality. EI is an objective measure of inequality irrespective of prevalence while WI is a combined measure of inequality and the average distribution of an indicator that puts more weight on the poor. Results The results suggest that wealth-based inequalities decreased significantly at the national level. For ID, both indices showed a decline in both HPS and LPS though the change in WI in HPS was insignificant. For ANC, there was a significant decrease in inequality using both indices in HPS but not in LPS. For PNC, there was a significant decrease in inequality using both indices in HPS, and when using WI in LPS, but not when using EI in LPS. Conclusion Overall, the first decade of India’s CCT programs saw an impressive reduction in EI for ID but less so for WI suggesting that the benefit of CCTs did not go disproportionately to the poor, which suggests that there is a need to reduce or eliminate the evident leakages. The improvement in uptake and inequality in ANC and PNC was not at par with ID, stressing the need to place greater focus on the continuum of care. The urban rural difference in HPS versus LPS in the changes in inequality reveals that infrastructure is important for CCTs to be more effective. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12563-9.
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Affiliation(s)
- Deepali Godha
- Independent Research Consultant, 16/1 South Tukoganj, 201 Sukh Sheetal II, Indore, MP, 452001, India.
| | - David R Hotchkiss
- Department of International Health and Sustainable Development, Tulane University, School of Public Health and Tropical Medicine, New Orleans, USA
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Mishra PS, Sinha D, Kumar P, Srivastava S. Spatial inequalities in skilled birth attendance in India: a spatial-regional model approach. BMC Public Health 2022; 22:79. [PMID: 35022008 PMCID: PMC8756682 DOI: 10.1186/s12889-021-12436-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/17/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite a significant increase in the skilled birth assisted (SBA) deliveries in India, there are huge gaps in availing maternity care services across social gradients - particularly across states and regions. Therefore, this study applies the spatial-regression model to examine the spatial distribution of SBA across districts of India. Furthermore, the study tries to understand the spatially associated population characteristics that influence the low coverage of SBA across districts of India and its regions. METHODS The study used national representative cross-sectional survey data obtained from the fourth round of National Family Health Survey, conducted in 2015-16. The effective sample size was 259,469 for the analysis. Moran's I statistics and bivariate Local Indicator for Spatial Association maps were used to understand spatial dependence and clustering of deliveries conducted by SBA coverage in districts of India. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of deliveries conducted by SBA. RESULTS Moran's I value for SBA among women was 0.54, which represents a high spatial auto-correlation of deliveries conducted by SBA over 640 districts of India. There were 145 hotspots for deliveries conducted by SBA among women in India, which includes almost the entire southern part of India. The spatial error model revealed that with a 10% increase in exposure to mass media in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Interestingly, also with the 10% increase in the four or more antenatal care (ANC) in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Again, if there was a 10% increase of women with first birth order in a particular district, then the deliveries conducted by SBA significantly increased by 6.1%. If the district experienced an increase of 10% household as female-headed, then the deliveries conducted by SBA significantly increased by 1.4%. CONCLUSION The present study highlights the important role of ANC visits, mass media exposure, education, female household headship that augment the use of an SBA for delivery. Attention should be given in promoting regular ANC visits and strengthening women's education.
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Affiliation(s)
- Prem Shankar Mishra
- Research Scholar, Population Research Centre, Institute for Social and Economic Change, Bengaluru, Karnataka 560072 India
| | - Debashree Sinha
- Research Scholar, Department of Development Studies, International Institute for Population Sciences, Mumbai, Maharashtra 400088 India
| | - Pradeep Kumar
- Research Scholar, Department of Survey Research & Data Analytics, International Institute for Population Sciences, Mumbai, Maharashtra 400088 India
| | - Shobhit Srivastava
- Research Scholar, Department of Survey Research & Data Analytics, International Institute for Population Sciences, Mumbai, Maharashtra 400088 India
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Saha R, Paul P. Institutional deliveries in India's nine low performing states: levels, determinants and accessibility. Glob Health Action 2021; 14:2001145. [PMID: 34914883 PMCID: PMC8682830 DOI: 10.1080/16549716.2021.2001145] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Despite the implementation of several national-level interventions, institutional delivery coverage remains unsatisfactory in India’s low performing states (LPS), leading to a high burden of maternal mortality. Objective This study investigates the levels, differentials, and determinants of institutional deliveries in LPS of India. The study also delineates a holistic understanding of barriers to delivery at health facilities and the utilization of the Janani Suraksha Yojana (JSY) specifically designed to improve maternal and child health of disadvantaged communities. Methods A cross-sectional study was conducted using data from the National Family Health Survey (NFHS)-4, 2015–16. The study was carried out over India’s nine LPS utilizing 112,518 women who had a living child in the past five years preceding the survey. Bivariate and multivariate regression analysis techniques were used to yield findings. Results Of the study sample, nearly three-quarters (74%) of women delivered in a health institution in the study area, with the majority delivered in public health facilities. The multivariate analysis indicates that women who lived in rural areas, belonged to disadvantaged social groups (e.g. Scheduled caste/tribes and Muslims), and those who married early (before 18 years) were less likely to utilize institutional delivery services. On the other hand, women’s education, household wealth, and exposure to mass media were found to be strong facilitators of delivering in a health facility. Meeting with a community health worker (CHW) during pregnancy emerged as an important predictor of institutional delivery in our study. Further, interaction analysis shows that women who reported the distance was a ‘big problem’ in accessing medical care had significantly lower odds of delivering at a health facility. Conclusions The study suggests emphasizing the quality of in-facility maternal care and awareness about the importance of reproductive health. Furthermore, strengthening sub-national policies specifically in underperforming states is imperative to improve institutional delivery coverage.
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Affiliation(s)
- Ria Saha
- Public Health Consultant, London, UK
| | - Pintu Paul
- Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University, New Delhi, India
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